International Pharmaceutical Excipients Council
Of The Americas
APPLICATION FOR ASSOCIATE MEMBERSHIP
Date ____________________
To the Executive Committee of the International Pharmaceutical Excipients Council of
the Americas:
We, the undersigned, hereby make application for Associate Membership in the
International Pharmaceutical Excipients Council of the Americas. It is understood and
agreed that our purpose in joining is to assist in improving business conditions affecting
common interests of all members of the Council and that we qualify for membership as
set forth in Article III, Section 1(c) of the Council’s bylaws in that our business does not
regularly involve the production or manufacture of:
(i)
(ii)
(iii)
pharmaceutical or other excipients
bulk excipient formulations (e.g., excipient blends); or
finished dosage pharmaceuticals or delivery systems containing
pharmaceuticals or other excipients.
It is further understood and agreed that if we are elected to membership in the Council
the undersigned will pay its annual dues as required on February 1st of each year; except
that during the year in which a member is elected, a pro-rata payment only shall be
required that is based upon the unexpired quarters remaining in that year.
Firm Name________________________________________________________
Address___________________________________________________________
City_____________________________State___________Zip Code___________
Telephone____________________Fax________________E-mail_____________
International Pharmaceutical Excipients Council
Of The Americas
Application for Associate Membership
Page Two
The applicant is a corporation___________, partnership ____________or
individual_____________.
Its Associate Membership category is (check one):
Graduate Students - $30 annual dues
Current graduate students in pharmacy
and related sciences
____________
Academic - $125 annual dues
Current or retired faculty of school of
pharmacy and related sciences
____________
Not for Profit Scientific Organization
$250 annual dues
Bodies organized for the advancement of science
and composed of individuals as opposed to firms
____________
Individual Consultants - $375 annual dues
Persons who offer professional services and small
firms with not more than 2 employees
____________
Pharmaceutical Industry Associations
____________
$375 annual dues
Groups organized to advance the business, scientific, and legal/regulatory
interests of corporate members which manufacture or market
market pharmaceutical preparations
Excipient Distributors and Suppliers
____________
of Specialized Services - $2,500 annual dues
Excipient suppliers and distributors who choose not to apply for full membership,
industry publications, larger consulting firms, and companies or firms which offer
contract testing, development research, manufacturing, packaging or marketing
services, GMP training, etc.
Associate members are eligible to serve as members of any standing or other committee
except the Executive Committee, to attend Board of Trustees and public meetings of the
Council, and to receive all general membership mailings. However, Associate members
have no voting rights and may not hold elective office.
International Pharmaceutical Excipients Council
Of The Americas
Application for Associate Membership
Page Three
Name and title of individual designated as the Associate Member’s “Official
Representative” (O.R.) (please type or print):
Name____________________________________________________________
Title_____________________________________________________________
Address__________________________________________________________
City_____________________________State___________Zip Code__________
Telephone_______________Fax________________E-mail_________________
Name and title of individual designated as an alternate representative:
Name___________________________________________________________
Title____________________________________________________________
Address_________________________________________________________
City____________________State_________________Zip Code ___________
Telephone_____________ Fax_____________ E-mail___________________
Names and titles of other company officials who should receive Council mailings
(please type or print):
Name____________________________________________________________
Title_____________________________________________________________
Address__________________________________________________________
City_____________________________State___________Zip Code__________
Telephone________________Fax_______________E-mail_________________
Name____________________________________________________________
Title_____________________________________________________________
Address__________________________________________________________
City_____________________________State___________Zip Code__________
Telephone________________Fax_______________E-mail_________________
Name____________________________________________________________
Title_____________________________________________________________
Address__________________________________________________________
City_____________________________State___________Zip Code__________
Telephone________________Fax_______________E-mail_________________
International Pharmaceutical Excipients Council
Of The Americas
Application for Associate Membership
Page Four
We are interested in participating in activities of the committee(s) noted below and
would like to receive information on any subcommittees or technical working groups:
Compendial Review/Harmonization
____________
Excipient Composition
____________
Excipient Qualification
____________
Good Manufacturing Practices
____________
Quality by Design Product Development
____________
Regulatory Affairs
____________
Safety
____________
USP Liaison
____________
Validation Working Group
____________
We would appreciate knowing your Company’s reason/primary interest in joining
IPEC-Americas:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Signed ______________________________________________
Title ________________________________________________
Applications should be returned to:
Kimberly R. Beals, CAE
Executive Director
3138 10th Street N
Suite 500
Arlington, VA 22201
Tel: 571-814-3451
Email: ipecamer@ipecamericas.org